Division of Professional Licensure

Division of Professional Licensure

Office of Public Safety and Inspections 1000 Washington Street Suite 710, Boston, MA 02118

APPLICATION FOR APPROVAL OF CONTINUING EDUCATION PROGRAM

All individuals or organizations seeking approval to operate as a Training Facility that offers one or more Continuing Education course(s) shall submit an application as well as a copy of all curriculums, training materials, Certificates of Completion to be used by the facility, and a list including the names and Massachusetts Hoisting Machinery License numbers of all Instructors. Curriculum must contain the minimum topics and associated hours for those topics as listed in 520 CMR 6.04(1) (b) 6.

Name of School/Program: __________________________________________________ Telephone #: _____________________

Location Address: _________________________________________________________________________________________

(Street)

(City)

(State)

(Zip Code)

Name of Program Coordinator: _______________________________________________________________________________

Mailing Address (Program Coordinator): _______________________________________________________________________

(Street)

(City)

(State)

(Zip Code)

Telephone #: _____________________________

E-mail Address: _____________________________________________

**Please submit a legible photocopy of the Course Monitor's Massachusetts Hoisting License**

Name of Course Monitor: ___________________________________________________________________________________

Mailing Address (Monitor): _________________________________________________________________________________

(Street)

(City)

(State)

(Zip Code)

Telephone #: ___________________ E-mail Address: ______________________________ SSN #: ___________________

(Mandatory)

Hoisting License #: ___________________ License Restriction(s): ___________________ Expires: ___________________

CURRICULUM AND TRAINING MATERIALS

Please submit a copy of your curriculum and training materials for the suitable Regulatory and Industry Standard Training and each restriction that complies with the listed hours below and the requirements of 520 CMR 6.04(1) (b) 6.*

REGULATORY AND INDUSTRY STANDARD TRAINING For all Hoisting licenses except for the restrictions listed below For Hoisting licenses with 1D, 4B, 4C, 4D, 4E, 4F, and/or 4G restriction(s) only

2 HOURS 1 HOUR

CLASS 1 HOISTING

CLASS 2 EXCAVATING

2 HOURS (each)

2 HOURS (each)

1A - Derricks / Lattice Cranes 1B - Telescoping Boom

w/cables cranes 1C - Telescoping booms w/o

cables, forklifts

1 HOUR (each) 1D - General industrial

warehouse Fork Lift equipment

2A ? Excavators 2B ? Front end loader/backhoes 2C ? Front end loaders /

unloaders 2D ? Compact Hoisting

Machinery

CLASS MUNICIPAL-LIMITED

5 HOURS (total)

CLASS 3 ELECTRIC & PNEUMATIC

2 HOURS

3A ? Electric & Pneumatic

CLASS 4 SPECIALTY

1 HOUR (each)

4B - Drill Rigs 4C - Pipeline side booms 4D - Concrete Pumps 4E - Catch Basin Cleaner 4F - Sign Hanging Equipment 4G - Specialty Side Boom Mowers

1C - Telescoping booms w/o cables, forklifts 2B - Front end loader/backhoes 4G - Specialty Side Boom Mowers

(2 hours) (2 hours) (1 hour)

Revised August 2018

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* A licensee who holds a Hoisting license with multiple classes shall complete only two (2) classroom hours of Regulatory & Industry Standard Training and the equipment specific training for each class applicable to their hoisting license, in accordance with 520 CMR 6.04(1) (b) 7.

CERTIFICATES OF COMPLETION

Continuing Education Programs must submit a copy of their Certificates of Completion for approval. Certificates of Completion shall contain the following information:

a. Name of participant; b. Address of participant; c. E-mail address of participant; d. Massachusetts License grade and number of participant; e. Name and address of the institution or organization providing the continuing education/assessment; f. A printed name and legible signature of a Licensee verifying participant has completed the hours as listed on the

certificate; and. The License number of the Licensee endorsing the certificate; h. Date of issuance.

Each program must provide a means to ensure certificate authenticity and shall provide evidence of the means of certification to the Office. Such means shall include:

a. School embossment of certificate; or b. Computer data transfer of program participants to the Office; or c. Signature verification; or d. Numbered certificates and a list of corresponding Licensees.

LIST OF CONTINUING EDUCATION INSTRUCTORS

Please list all the names, Massachusetts Hoisting Machinery License numbers, and submit legible photocopies of the Massachusetts Hoisting Licenses of the Instructors that will be part of the Continuing Education Program (please attach additional documentation to this application if additional space is required)

Name

Hoisting Number

Restrictions

Expiration Date

Revised August 2018

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PREREQUISITES

ALL of the following items MUST be submitted with this application in order for your application to be processed properly. Failure to submit all required information will result in unnecessary delays.

A completed application. Copy of your curriculum(s) and training materials for the Regulatory and Industry Standard Training and each restriction. Copy of Certificates of Completion to be used by the Continuing Education Program. List of all the names, Massachusetts Hoisting Machinery License numbers, and legible photocopies of the Continuing Education Instructors' Massachusetts Hoisting Licenses.

I certify under the penalties of perjury that to my best knowledge and belief the statements herein made are true and correct; that the application is made in good faith; that I have complied with all the requirements of law; and that I meet all qualifications for approval by the Office of Public Safety and Inspections under 520 CMR 6.00. I further understand that a false statement made in this application is sufficient cause of rejection or revocation of a Continuing Education Program. I certify under the penalties of perjury that to my best knowledge and belief, I have filed all state tax returns and paid all state taxes required under law.

___________________________________________ Signature of Program Coordinator

___________________________________________ Signature of Course Monitor

___________________________________________ Date

___________________________________________ Date

Revised August 2018

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